Raka'a
1. Gabatarwa zuwa Hankali na Artificial a cikin Jiki: Iyakoki, Tabbatarwa, Nauyi da Da'a 2. Daftarin Shirin Motsa Jiki: Sauri da Amintacce Gyara tare da Hankali na Artificial 3. Binciken Motsi da Matsayi: Bidiyo da Hankali na Artificial 4. Bin Saƙon haƙuri, Biyayya da Ƙarfafawa 5. Rubutun Rubutun Rahoto da Ci gaba 6. Samar da abun ciki na Ilimin haƙuri: Kasida, Shirin Gida da Lacca 7. Aiki na tushen Shaida: Nazari na Adabi da Shaida 8. Takardun asibiti da Bayanan kula da SABULU 9. Jama'a na Musamman: Neurological, Pediatric, Geriatric, Orthopedic da 'Yan wasa 10. Tele-rehabilitation da Nesa Kulawa 11. Sirri, KVKK, Da'a da Tsaron Bayanai 12. Ƙarshe-zuwa-Ƙarshen Ƙarshen Aiki: Haɗuwa, Inganci da Gaba a cikin Clinic
Naúrar 5 / 12

Rubutun Rubutun Rahoto da Ci gaba

Riba:

  • Ikon canza binciken binciken, sakamakon aunawa da maƙasudi zuwa madaidaicin daftarin rahoton kimantawa tare da AI
  • Ƙarfin don kula da bambanci tsakanin abubuwan da aka samo asali, ma'auni na haƙiƙa, kimantawa da shirin (ƙwararrun SOAP) a cikin rahoton.
  • Ability don gane lambobi da jimlolin da AI za su iya ƙirƙira da kuma tabbatar da kowane bayanai tare da ma'aunin tushe

A cikin ilimin lissafi, rahoton shine ƙwaƙwalwar dindindin na aikin asibiti. Rahoton kimantawa ya rubuta matsayin farkon majiyyaci, kuma rahoton ci gaba ya rubuta canjin akan lokaci. Ana buƙatar waɗannan rahotanni don bibiyar asibiti, sadarwa ga majiyyaci, rajistar doka, da kuma biyan kuɗi (inshorar / cibiya). Rubutun rahoto mai kyau yana ɗaukar lokaci kuma shine aikin da ke sa likitocin ilimin motsa jiki su gaji a teburin su. Hankali na wucin gadi (AI) yana adana babban lokaci anan ta hanyar juya binciken bincikenku da ma'aunin ku zuwa madaidaicin daftarin rahoton da za'a iya karantawa. Amma wannan shine inda kuskuren AI mafi haɗari ya ta'allaka: yin lambobi ba shi da shi. A cikin wannan rukunin, zaku koyi yadda ake rubuta rahotanni cikin sauri da aminci tare da AI.

Tsarin rahoton: dabaru na SOAP

Tabbataccen rahoton likitancin jiki gabaɗaya yana bin dabaru na SOAP. SABULU ya ƙunshi sassa huɗu: S (Subjective) bayanin majiyyaci na kansa (zafi, ƙararrawa, manufa); O (Manufa) abubuwan da za a iya aunawa (kewayon motsi, ƙarfin tsoka, edema, gwaje-gwaje); A (Kima) fassarar asibiti na likitancin jiki da yanke hukunci na ci gaba; P (Shirin) shine mataki na gaba. Wannan bambance-bambancen yana da mahimmanci saboda haɗawa da haƙiƙa yana rage ƙimar asibiti na rahoton. AI yana tsara wannan tsari sosai, amma dole ne ku samar da mahallin.

Tsanaki: Idan ka gaya wa AI don "rubuta rahoton wannan majiyyaci" kuma ba a ba da ma'auni ba, AI na iya cika ɓangarorin tare da lambobi masu kyan gani amma gabaɗaya (misali ƙimar da ba ku taɓa aunawa ba, kamar "jingin gwiwa 120 °"). Wannan bayanan yaudara ne da ke shigar da fayil ɗin majiyyaci kuma babban haɗari ne na asibiti / doka. Doka: AI yakamata ya tsara bayanan da kuke bayarwa kawai, ba samar da bayanai ba.

Mataki-mataki: Ba da rahoton ƙirƙira tare da AI

  1. Tattara bayanai. Samo jarrabawar, ma'auni, gwaje-gwaje da bayanan majiyyaci su wanzu kuma daidai.
  2. Bayanan sirri da tsari. Canja wurin ma'auni zuwa AI tare da bayyanannun alamun (misali "ROM flexion gwiwa: 95°"); ganewa.
  3. Yi doka "Yi amfani da bayanan da na bayar kawai." Hana AI daga dacewa da filayen da suka ɓace; Idan ya ɓace, rubuta "NO DATA".
  4. Nemi daftarin aiki a tsarin SOAP. Kula da bambancin ra'ayi/manufa/ kimantawa/tsari.
  5. Daidaita kowace lamba da tushen. Tabbatar da kowace ƙima a cikin rahoton gaba ɗaya daidai da rikodin ma'aunin ku.
  6. Kuna rubuta ko amincewa da bita na asibiti. Sashe na kimantawa (A) shine tunanin ku na asibiti; Ko da AI ya ba da shawara, kuna da magana ta ƙarshe.
  7. Tabbatar, sa hannu, ajiyewa. Rahoton bai cika ba tare da amincewar likitan ilimin lissafi ba.

Karama guda uku (a cikin lambobi)

Case 1 - Gudun gida na karya. Masanin ilimin motsa jiki kawai ya ba AI "ROM ɗin satar kafada: 110 °", amma lokacin rubuta rahoton, AI ya ƙara ƙimar "70°" da ba a taɓa bayarwa ba don juyawa na ciki. Likitan physiotherapist ya lura da wannan kuma ya goge shi; domin bai auna jujjuyawar ciki a wancan zaman ba. Darasi: AI yana kula da cika rashi; Dokar "filin da ba a bayar ba = NO DATA" yana ceton rayuka.

Hali na 2 - Rahoton ci gaba. Marasa lafiya mara ƙarancin baya na yau da kullun, makonni 6. Baseline: Oswestry nakasa maki 42, zafi 6/10. Karshe: Oswestry 24, zafi 3/10. Likitan physiotherapist ya ba da waɗannan nau'i biyu na ainihin dabi'u; AI ya juya waɗannan zuwa ingantaccen ginshiƙi na ci gaba da sakin layi na taƙaice. Lokaci: An rage mintuna 20 na rubuce-rubuce zuwa mintuna 4, duk lambobi na gaske ne.

Case na 3 - Matsala / rudani mai ma'ana. Likitan physiotherapist ya manna danyar bayaninsa; Rubutun ya gauraye. An nemi AI don yin nazari a cikin SOAP. AI ya sanya "mara lafiya ya kwatanta taurin safiya" a cikin sashin haƙiƙa; Mai ilimin hanyoyin kwantar da hankali ya matsar da wannan zuwa sashe na ainihi (S) saboda bayanin majiyyaci ne, ba ma'auni ba. AI da aka gudanar, bambancin asibiti ya fito ne daga likitan ilimin lissafi.

Rauni mai ƙarfi / Ƙarfi mai ƙarfi

Rauni: "Rubuta rahoton ci gaba ga wannan majiyyaci: ciwon baya mai tsanani, ingantawa."

Babu bayanai; AI ya dace da ma'auni, maki da cikakkun bayanai. Sakamakon rahoton karya ne amma tabbatacce.

Ƙarfafa: "Rubuta rahoton ci gaba na DRAFT a cikin tsarin SOAP tare da ma'auni na ainihi da ke ƙasa. Yi amfani da bayanan da na bayar kawai; kada ku sanya kowane lambobi da ban bayar ba, rubuta 'NO DATA' a cikin filayen da suka ɓace. Rubuta sashin Evaluation (A) a matsayin shawara kuma zan sake duba shi. Bayanai: [tushe da ma'auni na yanzu]."

Samfura huɗu masu kwafi

Matsayi: Mataimakin takardun asibiti (kada ku samar da bayanai).Aiki: Rubuta rahoton kimantawa na DRAFT a tsarin SOAP. Doka: Yi amfani da bayanan da ke biyowa KAWAI. DATA yankin da ba a bayar ba, rubuta "BABU DATA".Bayani: - Maudu'i (S): [maganganun marasa lafiya, manufa] - Manufar (O): [ROM, karfi, gwaji, ƙimar ma'auni]Rubuta sassan Assessment (A) da Plan (P) azaman SHAWARA; Ina da yarda.

Aiki: Sanya ɗanyen bayanin kula na cikin SOAP.Raw bayanin kula: [mixed bayanin kula] Doka: Sanya kowace sanarwa a daidai sashe. Abin da mai haƙuri ya ce = S (subjective), abin da na auna = O (manufa). Idan ba ku da tabbas, sanya alamarin a matsayin "[SASHEN RASHIN WARWARE]". Kada ku ƙara sabon bayani, kawai gyara shi.

Aiki: Samar da jadawalin ci gaba da taƙaitawa. Bayanai: Baseline [darajar] / na yanzu [darajar] (dated). Ina so: (1) ginshiƙi kwatanta gefe-da-gefe, (2) taƙaitaccen haƙiƙa a cikin jimloli 3-4. Kawai amfani da lambobin da na bayar; Kada ku wuce gona da iri, ku bar min hukuncin asibiti.

Aiki: Duba kowane lamba a cikin daftarin rahoton. Draft: [Rahoton AI] Ina so: Lissafta kowane ƙimar haƙiƙa a cikin rahoton kuma sanya shafi akansa "yana cikin ma'aunin tushe? (e/a'a/ duba)". Tuta kowace ƙima wacce ba za a iya tantance ta azaman jan tuta ba.

Rahoton ginshiƙi kula da inganci

kashi

Ikon AI

Alhakin likitan physiotherapist

tsari / oda

Yana shigar da tsarin SOAP mai tsafta

Tabbatar da rabuwa

Harshe / iya magana

Mai iya karantawa, marubuci mai daidaituwa

Sauke furucin da ya wuce kima

Ƙimar aunawa

Tsari

Daidaita kowace lamba da tushen, kama ta karya

Fassarar asibiti (A)

yana ba da shawarwari

Hukuncin asibiti naku ne; tabbatar ko canza

Maida doka/koda

Tsarin tunatarwa

Tabbatar da cikar filayen da ake buƙata

Tukwici: Koyaushe gudanar da daftarin rahoton ta hanyar "lambar duba" zagaye (samfuri na huɗu). Mafi hatsarin abin da AI zai iya yi ba da'awar ba ne, amma ƙimar ma'aunin karya wanda ya yi kama da abin gaskatawa.

Wani muhimmin aiki na rahoton shine sadarwa. Rahoto iri ɗaya ne masu karatu daban-daban ke karantawa: likitan da ke magana, ƙwararren mai biyan kuɗi, wani mai ilimin motsa jiki a cikin ƙungiyar, wani lokacin kuma mai haƙuri da kansa. Don haka, harshe yana buƙatar zama duka daidai a asibiti kuma ba tare da jargon da ba dole ba. AI yana da kyau a sake rubuta abun ciki na asibiti a cikin sautuna daban-daban don masu karatu daban-daban; Alal misali, zai iya samar da ainihin bayanai guda ɗaya daga ƙayyadaddun fasaha don likita da kuma taƙaitaccen taƙaitaccen bayani ga mai haƙuri. Koyaya, lambobin da hukuncin asibiti dole ne su kasance daidai ɗaya a cikin nau'ikan biyu; Sautin na iya canzawa, gaskiyar ba za ta iya ba. Kuskuren da ya fi dacewa lokacin samar da nau'ikan don masu karatu daban-daban shine ba da cikakken bayani game da gano lokacin da aka sauƙaƙa; don haka tabbatar da kowace sigar daban.

Daidaitaccen ma'auni da harshen manufa

Kyakkyawan rahoto yana bayyana ci gaba ta hanyar daidaitattun matakan, ba ra'ayi na zahiri ba. There are commonly used outcome measures in physiotherapy: Visual Analog Scale (VAS) or Numerical Rating Scale (NRS) for pain, Oswestry Disability Index for the waist, Neck Disability Index for the neck, patient-specific functional scale for general function. Waɗannan ma'auni suna yin ci gaba mai ƙididdigewa da kwatankwacinsu. AI na iya juya sakamakon waɗannan ma'auni zuwa tebur mai tsafta da jumlar jumla; Amma ƙa'idodin da kuke amfani da su a zahiri da ainihin maki suna da mahimmanci. Wani aiki mai ƙarfi shi ne rubuta manufofin da za a iya aunawa: "marasa lafiya zai iya yin tafiya na minti 20 ba tare da jin zafi ba a cikin makonni 6" maimakon "mara lafiya zai samu lafiya." AI yana da kyakkyawan taimako wajen sanya maƙasudin maƙasudin ma'auni; Kuna tabbatar da cewa makasudin gaskiya ne kuma ya dace da mai haƙuri.

Tukwici: Koyaushe rubuta ƙimar farawa, ƙimar yanzu da manufa tare a cikin rahoton. Wannan ukun yana nuna ci gaba da sauran nisa a kallo; Shine mafi kyawun tsari ga duka majiyyaci da sashin biyan kuɗi.

Kuskuren gama gari

  • Neman rahoto ba tare da samar da bayanai ba. AI ta cika guraben da aka yi lambobi.
  • Ba yin tsarin "sake shi" ba. Idan ba a hana shi a sarari ba, AI za ta yi ƙoƙarin cike filayen da suka ɓace.
  • Ba duba lambobin ba. Dole ne kowace ƙima a cikin rahoton ta dace da ma'aunin tushe.
  • Barin fassarar asibiti zuwa AI. Sashe na kimantawa (A) shine hukuncin likitancin jiki.
  • Rudani mai ma'ana/manufa. Bayanin mara lafiya bai kamata ya rikice tare da ma'auni ba.
  • Amfani ba tare da izini ba. Daftarin da ba a sanya hannu ba, ba a sake duba shi ba rahoton hukuma ba ne.

A takaice

AI yana adana babban lokaci a rubuce-rubucen rahoto: yana kafa tsari, daidaita harshe, yana tsara ma'auni. Amma kuskurensa mafi hatsari shine yin lambobi. Bukatar shi don amfani da ainihin bayanan da kuka bayar kawai, buga "NO DATA" a cikin filayen da suka ɓace. Bincika kowace ƙima ta haƙiƙa tare da ma'aunin tushe, kula da bambancin ra'ayi/manufa, tabbatar da fassarar asibiti da kanku kuma sanya hannu kan rahoton azaman likitan physiotherapist.

Aikin aikace-aikace

Shirya ainihin (ko na gaske) na farko da na yanzu na ma'auni. Samar da daftarin rahoton SOAP tare da samfuri na farko, da ginshiƙi na ci gaba tare da samfuri na uku. Sannan yi rajistar lamba tare da samfuri na huɗu: da gangan barin wurin da ya ɓace a cikin shaci kuma bincika idan AI ta haɓaka. Idan akwai ƙirƙira, ƙarfafa ƙa'idar "NO DATA".

jerin abubuwan dubawa

  • [ ] Na ba da ainihin bayanan ma'auni na ainihi ga AI.
  • [ ] Na sanya dokar "Kada ku sanya filin da ba a bayar ba, rubuta BA DATA".
  • [ ] Na tabbatar da bambance-bambancen sashin SOAP (ma'anar / manufa / kimantawa / shirin).
  • [ ] Na tsara kowace lamba a cikin rahoton daidai ga ma'aunin tushe.
  • [] Na rubuta ko amincewa da sharhin asibiti (A).
  • [ ] Na bita kuma na sanya hannu kan rahoton a matsayin likitan physiotherapist.
A baya Na gaba